Order Form (Model-A.org)

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Please complete this form and submit with your payment and trade-in, when you are purchasing a restored carburetor or when requesting restoration services.

To be filled out and sent with payment and trade-in:

Name: Address: City: State: ZIP: Country: Phone: Email:

Service Desired

Service Requested: Your Carburetor Restored or Repaired Restored, Zenith Model A Carburetor ($195.00 each): Number of Zenith trade-ins: Trade-in, Zenith carburetors Are Requested

If you do not have a Zenith trade-in, add $75.00 for each.

Special needs, comments, etc.: